Presentazione di PowerPoint

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The roadmap for trombolysis in outpatients with
acute stroke
Luca Puccetti, Mirene Anna Luciani, Giovanni
Orlandi, Alberto Chiti
GP, SMIPG - SIT Institute of Neurology,
University of Pisa Training physician in
family medicine
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BACKGROUND

• Intravenous trombolysis (IT) performed within 3
  hours in suitable patients with ischemic stroke
  reduces both mortality and disability TIME IS
  BRAIN
• Although these benefits are evident few patients
  with stroke undergo IT (less than 5), even in
  best situations, because of
• UNAWARENESS or INSENSITIVITY
• - DELAY (OUT and IN Hospital)
• OBJECTIVES
• Increase awareness and interest
• REDUCE DELAY

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Tasks for community physicians
1) Sharing patients medical information
(patients summary and EHR) 2) Sensitizing
community physicians to realize the benefits
associated with VT in acute stroke and to
cooperate to make it possible 3) Training of
community physicians on inclusion and exclusion
criteria 4) Tele-consultation with the onboard
neurologist or with the Emergency Center 5)
Follow-up
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Venous Trombolysis in outpatients

• DEDICATED MODIFIED AMBULANCE
• On board specifically formed Team including
  skilled neurologist
• On board automated laboratory analyzer (clotting
  and blood count)
• Moveable cranial CT (350 Kg), 8 slices
• Local first evaluation of imaging by the
  neurologist on board
• Sending of images via UMTS-HSPDA/SAT to the
  Neuroradiological Center of the AOUP (University
  of Pisa) for legally refertation
• Assessment of inclusion and esclusion criteria
• Trombolysis if indicated and subsequent transport
  to the Stroke Unit or to the Neurosurgical Center
  ICU if hemorrhagic stroke

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INCLUSION CRITERIA of the PILOT STUDY
1) PATIENTS 18 - 80 YEARS
2) Ischemic STROKE with moderate neurological
injuries (NIHSS 5-25) including also isolated
aphasia isolate (NIHSS 2-3)
3) IT within 3 hours of onset of symptoms
4) Symptoms for at least 30 minutes and not
significantly improved before treatment
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MAJOR ESCLUSION CRITERIA
LABORATORY CRITERIA Heparin in the last 48 hours
Actual Anticoagulants with INR gt 1,7 Platelet
count lt 100.000/mm3 Glycemia lt 50 o gt 400 mg/dl
CLINICAL CRITERIA Stroke with sezures Subarachno
id hemorrhagic symptoms, although normal CT
imaging Previous ischemic stroke with disability
(mRS gt2) Ischemic stroke in the last 3
months Previous intracranial hemorrhage Diseases
with high hemorrhagic risk Severe actual or
recent bleeding Recent (lt 10 days)
resuscitation manouvres severe trauma, delivery
Recent (lt 3 months) major surgical procedure
OTHER CRITERIA Intracranial , CT evident
hemorrage or early hypodensity in more than
? of the area of medium cerebral
artery Systolic pressure gt 185 mmHg, or
diastolic gt110 mmHg, uncontrollable
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Critical issues
HEMORRHAGIC STROKE (CT confirmed)
TELE NEUROSURGICAL-CONSULTATION
FAST SURGICAL PROCEDURES or ICU
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FACILITATION of INTRA-ARTERY Thrombolysis
Venous thrombolysis may facilitate the
Intra-artery thrombolysis which is indicated in
selected cases
Occlusion of medium cerebral artery within 3-6
hours from the onset of symptoms
Occlusion of basilar artery within 3-6 hours from
the onset of symptoms